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Institute of Medicine (US) Committee on Prevention of Obesity in Children and Youth; Koplan JP, Liverman CT, Kraak VI, editors. Preventing Childhood Obesity: Health in the Balance. Washington (DC): National Academies Press (US); 2005.

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Preventing Childhood Obesity: Health in the Balance.

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5Industry, Advertising, Media, and Public Education

To lead a healthier and more active lifestyle, many young consumers and their parents will need to alter their food and beverage preferences and engage in fewer sedentary pursuits in order to achieve energy balance. Market forces may be very influential in changing both consumer and industry behaviors. The food, beverage, restaurant, entertainment, leisure, and recreation industries must share responsibility for childhood obesity prevention and can be instrumental in supporting this goal. Federal agencies such as the U.S. Department of Health and Human Services (DHHS), the U.S. Department of Agriculture (USDA), and the Federal Trade Commission (FTC) all have the potential to strengthen industry efforts through general support, technical assistance, research expertise, and regulatory guidance. In addition, government is an important source of positive reinforcement. It can recognize industry stakeholders who are willing to take the financial risks of developing new products and services consistent with the goals of healthful eating behaviors and regular physical activity, thereby setting examples for other private-sector entities to follow.

INDUSTRY

American children and youth represent dynamic and lucrative markets. For example, food and beverage sales to young consumers exceeded $27 billion in 2002 (U.S. Market for Kids' Foods and Beverages, 2003). Similarly, young people are major consumers of the products and services of the entertainment, leisure, and recreation industries.

Providing young consumers and their families with the knowledge and skills to make informed and prudent choices in these marketplaces could be a key obesity prevention strategy. Industry continuously develops new products and services in response to changing consumer demand, and its primary emphases—sales trends, marketing opportunities, product appeal, and expanding market share for specific product categories and product brands (Datamonitor, 2002; U.S. Market for Kids' Foods and Beverages, 2003)—could be profitably shifted toward healthier and more active lifestyles.

Although the private sector has not historically viewed its responsibility as changing consumers' preferences toward healthier choices, changes are under way that acknowledge the essential role that industry may play in related policy dialogues, public/private partnerships, and research (Crockett et al., 2002).

The increased media coverage of childhood obesity in recent years, and the consequent growth in public attention and potential for litigation have sensitized the food and beverage industries to examine the underlying causes of the problem and learn from the tobacco industry experiences (Daynard, 2003; Appendix D). Moreover, it provides an opportunity for many types of industries (e.g., food, beverage, entertainment, recreation) to explore new marketing opportunities (Datamonitor, 2002). To the extent that consumers want to purchase and consume a healthful diet, engage in physical activity, and maintain energy balance, private industry not only has a profit incentive but a public relations incentive to help them meet that goal and demonstrate that industry can be responsive to public concerns.

The committee recognizes that children, youth, and their adult care providers are immersed in a modern milieu, including a commercial environment that could be shaped to encourage behaviors relevant to preventing obesity (Peters et al., 2002). Consumers may initially be unsure about what to eat for good health. They often make immediate trade-offs in taste, cost, and convenience for longer term health (Wansink, 2004). But numerous opportunities for influencing consumers' purchase decisions present themselves as the food and beverage industries develop, package, label, promote, distribute, and price products and as retail food stores, full-service restaurants, and fast food establishments make similar sets of decisions. Each of these points offers opportunities for influencing consumers' purchase decisions.

Developing healthier food and beverage products or serving smaller portion sizes may be viewed by some private-sector businesses as risks rather than as opportunities; making changes in the absence of broad-based consumer demand, whatever the market, conceivably can be seen as a risk to the private sector. But in this case there is ample precedent. A variety of food-industry stakeholders have recently made positive changes by expanding healthier meal options for young consumers (Hurley and Liebman, 2004; Richwine, 2004), offering improved food products with reduced sugar content for children (PR Newswire, 2004), and reducing portion sizes at full-service and fast food restaurants (Hurley and Liebman, 2004). These changes can and should occur on a much larger scale. For that to happen, coordinated efforts among industry, government, and other sectors are needed to stimulate, support, and sustain consumer demand for healthful foods and beverages, appropriately portioned meals, and accurate and consistent nutritional information made readily available to the public.

Similarly, the leisure, entertainment, and recreation industries are faced with the challenge of maintaining profitability while portraying active living1 as a desirable social norm for adults and children. These industries, which influence how leisure time is used, can create a wide range of new products and opportunities to increase energy expenditure through the incorporation of physical activity messages into sedentary pursuits (e.g., television commercials, video games and Internet websites that remind or prompt consumers to increase physical activity for a specified amount of time to balance screen time). This chapter presents a series of recommendations appropriate to the commercial environment in general and to various industries in particular.

Food and Beverage Industry

Product Development

The food and beverage industries' decisions are guided by key factors—including taste, palatability, cost, convenience, value, variety, availability, ethnic preferences, and safety—that drive consumer demand (FMI, 2003a,b; Wansink, 2004). The industry's decisions are also constrained by other conditions. For example, product and meal size are significant drivers of consumers' perceived value of the foods and beverages they purchase, whether for consumption at home or elsewhere (FMI, 2003a,b; Stewart et al., 2004; Wansink, 2004).

Similarly, modern retail food stores offer tens of thousands of food and beverage items from which to choose. While more than 14,000 new food and beverage products enter the U.S. marketplace annually, less than 6 percent are innovative enough to be successful (Heasman and Mellentin, 2001). The majority of these new products fail for a variety of reasons including lack of consumer demand, cost, marketing strategies, or lack of positive reinforcement or support from other groups (such as the public health sector and health-care professionals) (Heasman and Mellentin, 2001).

But failure in the past, particularly with regard to healthier food and beverage offerings, does not necessarily mean failure in the future. The financial success of diet carbonated beverages and the greater availability of reduced-calorie food and beverage products—buttressed in part by the reduced fat or saturated fat processed food products created by industry in response to the Healthy People 2000 objectives (NCHS, 2001)—are examples of how industry could be continually seeking new ways to meet consumer demand, earn a decent profit, and have its products positively affect public health.

Thus significant profit incentives now exist for industry to develop reduced-calorie and low-energy-dense foods, thereby helping consumers achieve their dietary and energy balance goals. Movement in that direction has already begun; food and beverage industries are currently seeking opportunities in product development and product reformulation, with an emphasis on eating for health (Datamonitor, 2002; FMI, 2003a). New products are also developed, packaged, and marketed to ethnically diverse children and youth with attention to cultural taste preferences and attractive packaging (Williams et al., 1993). The committee recommends that as new products are developed or existing products are modified by the private sector, it should be imperative that energy balance, energy density, nutrient density, and standard serving sizes are primary considerations in the process. This can be assisted by government stakeholders providing general support, technical assistance, research expertise, and regulatory guidance.

Energy Density of Foods

As discussed in Chapter 3, the energy density of a given food is the amount of energy it stores per unit volume or mass. At 9 kilocalories2 stored per gram, fat has the highest energy density. Alcohol stores 7 kilocalories per gram, carbohydrates and protein both store 4, fiber stores 1.5-2.5, and water stores 0.0—i.e., it does not provide energy. Energy density is a determinant of the effects of foods and macronutrients on satiety (Rolls et al., 2004a), and it may have a significant influence on regulating food intake and body weight as well (Drewnowski, 2003; Prentice and Jebb, 2003).

High-energy-dense foods, such as potato chips and sweets, tend to be palatable but may not be satiating for consumers, calorie for calorie, thereby encouraging greater food consumption (Drewnowski, 1998; Prentice and Jebb, 2003). Humans may have a weak innate ability to recognize foods with a high energy density to down-regulate the amount of food consumed in order to maintain energy balance, thereby fostering a “passive overcon-sumption” of these types of foods (Prentice and Jebb, 2003). By contrast, low-energy-dense foods, such as fruits and vegetables, contain more fiber and water and less fat than high-energy-dense foods. As a result, they promote satiety and reduce energy intake but may be considered less palatable by some individuals (Drewnowski, 1998; Rolls et al., 2004b). Consumers typically ingest fewer calories when meals are low in energy density than high in energy density (Kral et al., 2002; Rolls et al., 2004b). There is a need for further research on the implications of dietary energy density on the short-term and long-term physiological regulation of satiety, and the role of energy density in total energy intake and achieving a healthy body weight.

An analysis of the 1999-2000 National Health and Nutrition Examination Survey (NHANES) and NHANES III data revealed that three food groups—sweets and desserts, soft drinks, and alcoholic beverages—comprised nearly 25 percent of all calories consumed by Americans between 1988 and 2000. Salty snacks and fruit-flavored beverages accounted for another 5 percent, bringing the total calories contributed by high-energy-dense/low-nutrient-dense foods to be at least 30 percent of Americans' total calorie intake during that period (Block, 2004). Nutrient composition data available from fast food company websites suggest that average menus are twice the energy density of recommended healthful diets (Prentice and Jebb, 2003).

Developing low-energy-dense but palatable food products, which will help consumers achieve and maintain energy balance by reducing the probability of excessive energy consumption, has been a significant challenge for the food industry (Drewnowski, 1998). While acknowledging this challenge, the committee emphasizes the need to identify specific incentives that will help the industry develop such new products. In the meantime, manufacturers can modify existing products—for example, by replacing fat with protein, fruit or vegetable purée, fiber, water, or even air—to reduce energy density but maintain palatability without substantially reducing the product size or volume.

Product Packaging and Portion Sizes

Packaging is the “interface” between food-industry products and the consumer—that is, it is the public's first point of contact—and food packages implicitly suggest portion sizes or food combinations (e.g., which foods are eaten together such as peanut butter and jelly). But a product package can be modified in three general ways—by size, visual appeal, and the type and amount of information it provides (such as the nutritional content according to the Nutrition Facts panel on food labels)—in order to assist consumers in making knowledgeable purchasing decisions and determining portion sizes for themselves.

Because energy requirements vary both by age and body size (IOM, 2002), parents need to be aware of the appropriate amount of food that will help meet but not exceed their child's own energy needs. In order to do so at present, however, they must overcome an established and unhealthy trend; research has revealed a progressive increase in portion sizes of many types of foods and beverages made available to Americans from 1977 to 1998 (Nielsen and Popkin, 2003; Smiciklas-Wright et al., 2003), the same period during which a rise in obesity prevalence has been observed (Nestle, 2003b; Rolls, 2003).

Some research on the effects of food portion size has shown that children 3 years old and younger seem to be relatively unresponsive to the size of the portions of food that they are served (Rolls et al., 2000; see also Chapter 8). By contrast, the food intake of older children and adults is strongly influenced by portion size, with larger portions often promoting excess energy intake (McConahy et al., 2002; Rolls et al., 2002; Orlet Fisher et al., 2003). Children 3 to 5 years of age consumed more of an entrée and 15 percent more total energy at lunch when presented with portion sizes that were double an age-appropriate standard size (Orlet Fisher et al., 2003). Portions that are currently served and consumed at home, and particularly away from home, may be several times the USDA-recommended serving size or recommended caloric level3 (Orlet Fisher et al., 2003). In addition to food portion size, the frequency of eating and the types of foods consumed are important predictors of energy intake as children transition from being toddlers to preschoolers. One study that evaluated the relationship of food intake behaviors to total energy intake among children aged 2 to 5 years who participated in the Continuing Survey of Food Intakes by Individuals (CSFII) 1994-1996, 1998 found that eating behaviors and body weight were positively related to energy intake (McConahy et al., 2004).

Research also suggests that individuals tend to overconsume high-energy-dense foods beyond physiological satiety (Kral et al., 2004), especially when they are unaware that the portion sizes served to them have been substantially increased (Rolls et al., 2004a). Satiety signals are not triggered as effectively with high-energy-dense foods (Drewnowski, 1998), and large portions of them consumed on a regular basis are particularly problematic for achieving energy balance and weight management in older children and adults.

A variety of physiological processes are involved in the regulation of dietary intake, satiety, energy metabolism, and weight. These include the neural pathways that regulate hunger and influence food intake, gastrointestinal mechanisms involved in providing signals to the brain about ingested food, and adipocyte-derived factors that provide information about energy stores, as well as the genetic and environmental factors that affect these physiological processes (see Chapters 3 and 8). There are a variety of external cues that may also influence dietary intake such as portion size and package size. For example, there is some evidence to support the hypothesis that larger food package sizes encourage greater consumption than smaller food package sizes (Wansink, 1996), and external cues such as packaging and container size may contribute to the volume of food consumed (Wansink and Park, 2000).

Thus, although the committee recognizes the difficulties faced by the food industry in developing new packaging options for consumers, industry should explore, through research and test-marketing, the best approaches for modifying product packages—multipackages with smaller individual servings or standard serving sizes, or resealable packages—so that products palatable to consumers may remain profitable while promoting consumption of smaller portions. Moreover, the food industry should investigate other approaches for promoting consumption of smaller portion sizes and standard serving sizes.

Leisure, Entertainment, and Recreation Industries

Americans now enjoy more leisure time than they did a few decades ago. As discussed in Chapter 1, trend data collected by the Americans' Use of Time Study through time use diaries indicated that adults' free time increased by 14 percent between 1965 and 1985 to an average total of nearly 40 hours per week (Robinson and Godbey, 1999). Data from other population-based surveys, including the National Health Interview Survey, NHANES, Behavior Risk Factor Surveillance System (BRFSS), and the Family Interaction, Social Capital and Trends in Time Use Data (1998-1999), together with trend data on sports and recreational participation, suggest a significant increase in reported leisure-time physical activity in adults (Pratt et al., 1999; French et al., 2001a; Sturm, 2004).

Cross-sectional data from the National Human Activity Pattern Survey, based on the responses of 7,515 adults between 1992 and 1994, assessed time use and daily energy expenditure patterns of adults. Results suggested that sedentary and low-intensity activities dominated while leisure-time, high-intensity activities accounted for less than 3 percent of energy expenditure (Dong et al., 2004).

Americans are presented with trade-offs in how they allocate their time and money. Understanding how Americans in general, and children and youth in particular, use their leisure time will help to determine ways of promoting more physical activity into their lives. An analysis of time allocation and expenditure patterns for U.S. adults over the past several decades suggests that they are spending more time in leisure and travel or transportation and less time in productive home activities (e.g., meal preparation and cleanup) and occupational activities (Sturm, 2004). Leisure-time industries have exceeded gross domestic product growth for both active industries (e.g., bicycles, sporting goods, membership sports clubs) and sedentary industries (television, spectator sports). However, there has been a steeper growth in sedentary industries from 1987 to 2001—especially the growth of cable television and spectator sports (Sturm, 2004).

Trend data for children (spanning from 1981 to 1997) have shown that they now have less discretionary or free time—defined as time not spent eating, sleeping, attending to personal care, or at school—than they used to because more of their time is spent away from home in school, after-school programs, or daycare. There is also a noted increase in the amount of time children spend in organized sports (Hofferth and Sandberg, 2001; Sturm, 2005a), but active transportation (e.g., bicycling or walking) is not a significant source of physical activity for children and youth (Sturm, 2005b).

Modern technologies such as labor-saving home appliances have reduced the energy expended for home meal preparation and the amount of time needed to achieve the same task (Sturm, 2004). Other technological innovations such as home entertainment devices (including cable television, computers, video games) and automobiles have contributed to sedentary behaviors among Americans, causing them to expend less energy. This phenomenon of increased time spent in passive sedentary pursuits relative to active leisure activities has been associated with the rise in obesity (French et al., 2001a; Philipson and Posner, 2003). However, although the average American adult spends more than 20 hours per week watching television, videos, or digital video discs (DVDs), it is notable that the largest increase in television watching occurred prior to 1980, which preceded the obesity epidemic (Sturm, 2004). The leisure, entertainment, and recreation industries can help counter the physical inactivity trend by promoting active leisure-time pursuits, while at the same time developing new products and markets. The introduction of products that involve more physical activity by some industry leaders suggests that some already believe they can create a significant market for these types of products.

Some companies have used popular athletic figures, who are potential role models for active and healthful lifestyles, to promote sedentary lifestyles. Instead, the industries could leverage their existing relationships with celebrities to convey messages that encourage physical activity and healthful living and reduce sedentary behaviors.

Some potentially positive efforts are now under way. One athletic apparel manufacturer provides funding to build, upgrade, or refurbish sports courts and other athletic facilities throughout the United States; awards grants to nonprofit organizations and governmental partners; supports physical education classes in elementary schools; and is a partner in Shaping America's Youth, a national cross-sectoral initiative for promoting physical activity and healthful lifestyles during childhood (Nike, 2004). Activity-based games offer opportunities for the leisure industry to market a product that promotes physical activity in children and youth. The evaluation of private-sector programs is crucial in order to assess if they are effective in increasing physical activity, especially among high-risk populations, and determine if they may have unanticipated and adverse consequences.

Full-Service and Fast Food Restaurant Industry

Increased consumption of food outside of the home has been one of the most marked changes in the American diet over the past several decades. In 1970, household income allotted to away-from-home foods accounted for 25 percent of total food spending; by 1999, it had reached nearly one-half (47 percent) of total food spending (Lin et al., 1999c). Total consumer spending on food dispensed for immediate consumption outside the home amounted to $415 billion in 2002 (Stewart et al., 2004). Similarly, a greater proportion of consumers' nutrients is now derived from foods purchased outside the home.

Consumption of away-from-home foods comprised 20 percent of children's total calorie intake in 1977, rising to 32 percent in 1994-1996 (Lin et al., 1999b). For adults, such foods provided more than one-third (34 percent) of total calories in 1995 (Lin et al., 1999a).

The frequency of dining out rose by more than two-thirds over the past two decades, from 16 percent in 1977-1978 to 27 percent in 1995 (Lin et al., 1999a). Restaurant industry sales for commercial and noncommercial services were projected to exceed $426 billion in 2003 (National Restaurant Association, 2003) and are forecasted to reach $440 billion in 2004 (National Restaurant Association, 2004). Moreover, consumer spending at restaurants is projected to continue growing over the next decade (Stewart et al., 2004). Full-service and fast food restaurants alike have been enjoying this boom—in 2003, full-service restaurant sales reached $153.2 billion and fast food restaurant sales reached nearly $121 billion (National Restaurant Association, 2003)—and it appears likely to continue. Assuming modest growth in household income and demographic changes, consumer per-capita spending between 2000 and 2020 is expected to rise by 18 percent at full-service restaurants and by 6 percent at fast food outlets (Stewart et al., 2004).

Given the growing public concern about the rise in obesity, particularly childhood obesity, full service and fast food restaurants throughout the country have begun offering healthier food options. At present, however, most restaurants do not provide consumers with the calorie and selected nutrient content either of offered meals or individual food and beverage items4; this information would be useful for making more prudent menu decisions. While the culinary qualities of fast food meals tend to differ from those of full-service restaurants (Lin et al., 1999a), both of them are typically energy dense and served in large portions.

Fast food consumption is associated with a diet that is high in total energy and energy density but low in micronutrient density. For example, an analysis of the CSFII 1994-1996 data for adult men and women revealed that a typical fast food meal provided more than one-third of their daily energy, total fat, and saturated fat intake; and that energy density increased while micronutrient density concurrently decreased with frequency of fast food consumption (Bowman and Vinyard, 2004).

Published data are limited that compare the nutrient content of full-service restaurant meals for children. However, one review of the entrees offered to children at 20 table-service restaurants found fried chicken on every one of the children's menus, a hamburger or cheeseburger on 85 percent of the menus, and french fries on all but one of the menus (Hurley and Liebman, 2004). At nearly one-half of the restaurant chains, french fries were the only side dish on the children's menus, and while children could generally choose a beverage from among soft drinks, juice, or milk, 10 of the restaurants offered free refills only for soft drinks (Hurley and Liebman, 2004).

Children and youth aged 11 to 18 years visit fast food outlets an average of twice per week (Paeratakul et al., 2003), and this frequency is associated with increased intake of soft drinks, pizza, french fries, total fat, and total calories, as well as with reduced intake of vegetables, fruit, and milk (French et al., 2001b). In a study of 6,212 children and adolescents between the ages of 4 and 19 years of age participating in the CSFII, those who ate fast food consumed more total energy, more energy per gram of food (greater energy density), more total fat and carbohydrates, more added sugars, more sweetened beverages, less milk, and fewer fruits and non-starchy vegetables than those who did not consume fast food (Bowman et al., 2004). Adolescents aged 13 to 17 years were found to consume more fast food regardless of whether they were lean or obese. Moreover, obese adolescents were less likely to compensate for the extra energy consumed by adjusting their energy throughout the day than were their lean counterparts (Ebbeling et al., 2004).

Expanding Healthier Meals and Food Choices

Given these trends and data, full-service and fast food restaurants should continue to expand their healthier meal options and food choices—particularly for children and youth—through the inclusion of fruits, vegetables, low-fat milk, and calorie-free beverages among their offerings. It is also important for restaurants to expand options for healthier children's meals, encourage parents to help their children make smarter eating choices, and remind parents of their rights as customers to substitute side dishes and customize meals to their satisfaction. Research is needed to monitor consumers' and children's responses to these expanded options.

Restaurants should also initiate a voluntary, point-of-sale, nutrition-information campaign for consumers. Meanwhile, in accordance with the recommendations of the Food and Drug Administration (FDA) Obesity Working Group's recommendations (FDA, 2004), consumers at restaurants should be encouraged to request information about the nutritional content of complete meals, foods, and beverages offered and consequently be provided with accurate, standardized, and understandable details at the point of sale. This nutritional information should include total calories, fat, cholesterol, and fiber, together with instruction on meaningfully interpreting these values within the context of typical consumers' total energy and dietary needs.

Nutrition labeling of restaurant meals and individual foods should take varying sizes or options into account and should be located near the price of the selections; this will ensure that the consumer is made aware of the information and that increased demand for healthful items and appropriate portions is made more likely. Moreover, the restaurant industry should explore price incentives that encourage consumers to order smaller meal portions. Research initiatives are needed to identify the most effective types of information formats on menus for encouraging the selection of healthful options (Stubenitsky et al., 1999).

As these suggested actions are costly endeavors, consideration must be given to the practicality of implementing these actions in cost-effective ways, especially in expensive restaurants where there is great variability in meals requested by patrons, and small or individual restaurants with limited food volume sales. It is also unclear who will be expected to pay for the nutrient analyses as well as the menu labeling itself. One option would be to encourage local public health departments to contract with dietitians in conducting nutrition education for the public and analyzing the nutrient content of menus. This would represent a new role for local government, but it could be developed by adapting current food safety and sanitation inspection services. It could also generate fees, so that the activity would be self-supporting and sustainable in the long-term; and it could be a convenient way to give public recognition to restaurants in compliance.

Providing Nutrition Education at Restaurants

In addition to voluntary point-of-service menu labeling, the committee recognizes that parents currently have limited nutrition information to rely on in order to select portion sizes and foods that are appropriate for their child. Thus, the committee encourages the restaurant industry to provide nutrition education that is consistent with the Dietary Guidelines for Americans and the FGP in order to inform parents and older youth about appropriate energy intake for meals intended for children and adolescents of different ages.

The Dietary Guidelines for Americans is a federal summary, issued jointly by DHHS and USDA every 5 years, that provides sound guidance to the public about food choices based on the current scientific evidence. The first edition was released in 1980 and provided seven guidelines. The fifth edition was released in 2000 and provided 10 guidelines clustered into three categories: aim for a healthy weight, build a healthy base, and choose sensibly (Ballard-Barbash, 2001).

The FGP was released in 1992 by USDA to teach consumers how to put the Dietary Guidelines for Americans into action. The FGP serves as the official food guide for the United States (USDA, 1992; Achterberg et al., 1994). The FGP illustrates the concepts of variety, proportionality, and moderation emphasized in the Dietary Guidelines for Americans (Achterberg et al., 1994; Dixon et al., 2001). In 1999, USDA developed an FGP for Young Children, based on the actual eating patterns of children aged 2 to 6 years, which aims to simplify educational messages and focus on young children's food preferences and nutritional requirements (USDA, 2003b; ADA, 2004).

These FGPs offer recommended daily serving sizes for each of the food groups, including bread, cereal, rice, and pasta; fruits; vegetables; milk, yogurt, and cheese; meat, beans, eggs, and nuts; and fats, oils, and sweets. Considerations used in determining serving sizes are the amount of a food that provides key nutrients, ease of use, and commonly recognized household measures of food and equivalents (USDA, 1999, 2000).

Unfortunately, despite the availability of the FGP and its adapted version specifically for younger children, most American children do not meet the recommended servings for fruit, dairy, and grain groups; and they do not meet the Dietary Guidelines' recommendations for total and saturated fat (ADA, 2004) (see Chapter 3).

The committee acknowledges that parents may have a difficult time understanding how portion sizes should be distributed for their children across an entire day, particularly when they are making selections at full-service and fast food restaurants. Another confounding factor is that younger children tend to eat smaller portions, compared to standardized serving sizes, more frequently throughout the day (McConahy et al., 2004). The current educational tools do not provide guidance pertinent to these considerations. The committee therefore encourages enhancing or adapting the existing FGP model,5 or developing a new food-guidance system and relevant educational materials, that will convey how portions should be distributed throughout the day for children of different age groups. (For example, if a child is in a particular age group, he or she should eat a certain proportion of energy at each meal—for example, 20 percent at breakfast, 30 percent at lunch, 30 percent at dinner, and 20 percent for snacks, and the appropriate temporal distribution of snacks should account for the duration of fasting overnight and for variations in daytime energy demands due to age and activity.)

Because such an enhancement could be used by parents to determine a single restaurant meal's percentage of their child's daily required total energy intake, encouraging restaurants to adopt this educational tool may promote children's consumption of smaller food portions. Additionally, the full-service and fast food restaurant industries should provide general nutrition information that will facilitate consumers' informed decisions about food and meal selections and appropriate portion sizes (consistent with the energy balance principles of the Dietary Guidelines for Americans and illustrated by the FGP). Finally, consumer research is needed to identify the most effective types of information formats on menus for encouraging the selection of healthful options.

Recommendation 2: Industry

Industry should make obesity prevention in children and youth a priority by developing and promoting products, opportunities, and information that will encourage healthful eating behaviors and regular physical activity.

To implement this recommendation:

  • Food and beverage industries should develop product and packaging innovations that consider energy density, nutrient density, and standard serving sizes to help consumers make healthful choices.
  • Leisure, entertainment, and recreation industries should develop products and opportunities that promote regular physical activity and reduce sedentary behaviors.
  • Full-service and fast food restaurants should expand healthier food options and provide calorie content and general nutrition information at point of purchase.

NUTRITION LABELING

The purpose of nutrition labeling is to provide consumers with useful information that will allow them to compare products and make informed food choices, thereby enhancing the likelihood of maintaining dietary practices and reducing the risk of chronic disease (IOM, 2004). In particular, the implementation of the regulations resulting from the 1990 Nutrition Labeling and Education Act (NLEA) was to be communicated in such a way that the public could “readily observe and comprehend such information and understand its relative significance in the context of a total daily diet” (FDA, 1993). The Nutrition Facts panel and nutrient and health claims that resulted from the NLEA are complementary approaches for providing guidance to consumers. They are discussed in turn below.

Nutrition Facts Panel

In 1993, the percent Daily Value (% DV) was added to the Nutrition Facts panel—a set of consistently formatted information items that are displayed on food product labels—to assist consumers in rapidly and efficiently understanding how various foods could fit into the context of a healthful diet. The Nutrition Facts panel's contents, regulated by the FDA, are specific to the food product or food-product category; they specify the number of servings per container and the key nutrients in a serving, according to the % DV for a 2,000-calorie-per-day diet (USDA, 2000; IOM, 2004). Serving sizes on the label are standardized so that consumers can compare nutritional information between products, even for packaged foods (such as frozen pizza) that contain ingredients from multiple food groups (USDA, 2000).

Data on consumers' actual use of the Nutrition Facts panel are limited since it was mandated by FDA in 1990. However, consumer research conducted by the FDA and the Food Marketing Institute (FMI) has found that one-half of U.S. adult consumers use food labels when purchasing a food item for the first time (FMI, 1993, 2001; Derby, 2002). The most common reason for using the label is to assess whether a product is high or low in a particular nutrient, especially fat, and the second most common use is to determine total calories (IOM, 2004).

Moreover, consumers often use the Nutrition Facts panel and the % DV to confirm a nutrient or health claim on the front of a product and to make product-specific judgments (Geiger et al., 1991; FDA, 1995). Consumer research indicates that the % DV in particular has been effective in helping consumers make judgments about different food products that are high or low in a particular nutrient and to put different food products in the context of a daily diet (IOM, 2004). Research shows that without the % DV, consumers could not accurately interpret metric values and distinguish between products (IOM, 2004).

Consumers generally report using the nutrition label more often to avoid rather than to purchase a specific food item (FMI, 1997). Research suggests that although food labels may influence some consumers under certain circumstances, particularly women, older consumers, and well-educated consumers (Kristal et al., 2001), many do not use the Nutrition Facts panel at all. This is attributed in part to lack of interest, lack of knowledge for using it appropriately, and difficulty of use (IOM, 2004). But even when consumers do have and understand the information, it may not change their behavior if their food purchases are primarily motivated by factors such as palatability, price, and convenience (Wansink, 2004).

The committee supports the FDA's current actions in exploring how best to revise the Nutrition Facts panel to prominently display products' standardized calorie serving and % DV (FDA, 2004). The committee endorses this as a step to assist consumers in making informed decisions to achieve energy balance. Energy requirements of children and adolescents differ by age, gender, and activity level. These differences are reflected in the Estimated Energy Requirements established in the Institute of Medicine's (IOM) report on Dietary Reference Intake values for macronutrients (IOM, 2002). However, the committee did not see a practical way in which the Nutrition Facts panel could incorporate all the % DV figures that would correspond to the energy needs of children at different ages (IOM, 2002; USDA, 2003a). Therefore, a recommendation to develop a specific % DV for children and youth based on age, gender, and three activity levels is currently not feasible.

FDA should establish mandatory guidelines for the display of total calorie content on the Nutrition Facts panel regarding products such as vending-machine items, single-serving snack foods, and ready-to-eat foods purchased at convenience stores—typically consumed in their entirety on one eating occasion. Although many prepackaged, ready-to-eat foods are provided in package sizes that may typically be consumed all at once, the nutrition label offers information only on one serving, as defined by the FDA standard serving size.

Thus, although the number of servings per package is also given, the purchaser must calculate the nutritional content of a multiple-serving portion that may be consumed at one sitting. For example, soft drinks are often sold in 20-ounce containers and are labeled as containing 2.5 servings. Because many consumers undoubtedly consume the entire 20 ounces and not precisely 8 ounces (one serving), which represents only 40 percent of the entire product, it would be easier for them to know the total nutritional value if this information was provided directly on the label.

Finally, the Nutrition Facts panel may be modified in other ways to enhance readability and consumer understanding (Kristal et al., 2001). Consideration should be given to the selection, organization, and display of nutrients to maximize the positive message and educational benefit conveyed by the label in order to assist consumers in making wise choices within a healthful diet while also serving to remind them to limit calories and other nutrients (e.g., cholesterol, fat) and thereby reduce their risk of chronic diseases related to obesity (IOM, 2004). In summary, the FDA, relevant industries, and other groups should conduct consumer research on the use of the nutrition label, on restaurant menu labeling, and on how to enhance or adapt the FGP or develop a new food-guidance system.

Nutrient Claims and Health Claims

A nutrient claim is a food-package statement consistent with FDA guidelines that characterizes the level of a nutrient in a food. Depending on the claim, the level is usually categorized as “free,” “high,” or “low.” With a few exceptions, a nutrient-content claim may be made by manufacturers only if a DV has been identified for that nutrient and the FDA has established, by regulation, the criteria that a food must meet in order to list the claim (IOM, 2004). An estimated 33.7 percent of products sold in 2000-2001 had nutrient content claims related to energy, total fat, saturated fat, cholesterol, dietary fiber, sodium, or sugars (Legault et al., 2004).

A health claim6 on a product package states that a scientifically demonstrated relationship exists between a food substance, legally defined as a specific food or food component, and a disease or health-related condition (IOM, 2004). Health claims (as well as nutrient claims) must be authorized by the FDA prior to their use in food labeling; the agency carefully assesses wording so that the claimed health-related relationship does not imply causation (IOM, 2004).

The FDA has approved 14 different health claims that may be used on food packages that emphasize both risks and benefits such as the relationship between heart disease and saturated fat; cancer and fruits and vegetables; and coronary heart disease risk and fruits, vegetables, grains, and soluble fiber (IOM, 2004). Approximately 4.4 percent of products sold in 2000-2001 had a health claim on their food package. The product groups with the highest percentage of health claims were hot cereal, refrigerated and frozen beverages, seafood, snacks (granola bars and trail mixes), eggs and egg substitutes, and meat and meat substitutes (Legault et al., 2004). These products provided a claim about the relationship between a diet low in saturated fat and cholesterol and a reduced risk of heart disease; high in soluble fiber and reduced risk of heart disease; and high in soy protein and reduced risk of heart disease (Legault et al., 2004).

Health claims advertising and labeling is product-specific so that the information imparted not only suggests a relationship between the food characteristics and health but also features a product that contains these characteristics (Mathios and Ippolito, 1999). Health claims, in conjunction with the Nutrition Facts panel, can help consumers make product-specific decisions and more informed food and beverage choices in the marketplace (Ippolito and Pappalardo, 2002).

The question has been raised as to whether the policy changes that occurred in the mid-1980s, which allowed food manufacturers to explicitly link diet to disease risks in advertising and labeling, assisted or confused consumers in making more healthful food choices to improve their diet (Mathios and Ippolito, 1999). An analysis that examined market share data in the ready-to-eat cereal market, consumer knowledge data, individual nutrient intake data, and per capita consumption data found that U.S. consumers' diets improved from 1985 to 1990 during the same time period that producers were permitted to use health claims in advertising and labeling (Mathios and Ippolito, 1999), although it is not possible to determine the role that health claims played in these positive outcomes. Evidence from the ready-to-eat cereal market indicates that allowing producers to use health claims resulted in more healthful product innovations and motivated competition based on healthful products (Mathios and Ippolito, 1999).

Thus, health claims may serve to stimulate industry to develop new products, or modify existing ones, that encourage positive changes in consumers' eating habits. Food and beverage companies would benefit from being able to use simple and easily understood health claims in order to stimulate increased consumer selection of healthier food products, including their own.

New health claims may be added to products through a process whereby a food manufacturer notifies the FDA of its intent to use a health claim based on scientifically accurate and authoritative findings. No health claims currently exist for products that explicitly address preventing obesity. However, it will be essential to develop a standard nutrient claim or health claim definition for energy density and nutrient density. For example, by developing a health claim for food products that have an energy density below 1 calorie per gram, such foods might be considered supportive of maintaining a healthy body weight. However, this type of health claim could not apply to beverages.7 A disclosure statement may be needed to accompany a health claim if consumer research reveals that a health claim on a food label would imply that a food is healthful in all respects (e.g., it has a low energy density but may not be nutrient dense) if this is not the case.

The regulatory environment in the early 1980s discouraged food and beverage manufacturers and advertisers from using health claims, but this policy was eased in 1993 when the FDA's health claim rules were revised (Ippolito and Pappalardo, 2002). The FTC has recently encouraged the FDA to consider giving manufacturers greater flexibility in making truthful, nonmisleading nutrient claims for foods,8 allowing comparative claims9 between different types and portion sizes of food, and permitting health claims that specifically relate reduced calorie consumption to decreasing the risk of obesity-related diseases (FTC, 2003).

The committee encourages the FDA to examine ways to give the food and beverage industries greater flexibility in making nutrient content and health claims that help consumers including children achieve and maintain energy balance. The committee also recommends that consumer research be undertaken to determine the best formats for health claims that relate lowered calorie consumption with reductions in the risk of obesity and obesity-related disease. Finally, the committee suggests that the government, academia, and private sector work together to conduct the necessary research on which to base such health claims.

Recommendation 3: Nutrition Labeling

Nutrition labeling should be clear and useful so that parents and youth can make informed product comparisons and decisions to achieve and maintain energy balance at a healthy weight.

To implement this recommendation:

  • The FDA should revise the Nutrition Facts panel to prominently display the total calorie content for items typically consumed at one eating occasion in addition to the standardized calorie serving and the percent Daily Value.
  • The FDA should examine ways to allow greater flexibility in the use of evidence-based nutrient and health claims regarding the link between the nutritional properties or biological effects of foods and a reduced risk of obesity and related chronic diseases.
  • Consumer research should be conducted to maximize use of the nutrition label and other food-guidance systems.

ADVERTISING, MARKETING, AND MEDIA

Children of all ages are spending a larger proportion of their leisure time using a combination of various forms of media, including broadcast television, cable networks, DVDs, video games, computers, the Internet, and cell phones (Roberts et al., 1999; Rideout et al., 2003). This trend has prompted concerns about the effects of these activities on their health (Kaiser Family Foundation, 2004). Children's exposure to advertising and marketing, particularly to the food, beverage, and sedentary-lifestyle messages delivered through the numerous media channels, may have a strong influence on their tendency toward increased obesity and chronic disease risk (Kaiser Family Foundation, 2004).

Advertising and promotion have long been intrinsic to the marketing of the American food supply (Gallo, 1999). Food and beverage companies and the restaurant industry together represent the second-largest advertising group in the American economy, after the automotive industry (Gallo, 1999), and young people are a major target. The annual sales of foods and beverages to young consumers exceeded $27 billion in 2002 (U.S. Market for Kids Foods and Beverages, 2003), and millions of dollars are spent annually by the food and beverage industry for specific product brands (Story and French, 2004). Food and beverage advertisers collectively spend $10 billion to $12 billion annually to reach children and youth (Nestle, 2003a; Brownell, 2004). Estimates are available for different categories of youth-focused marketing in the United States—more than $1 billion is spent on media advertising to children, primarily on television; more than $4.5 billion is spent on youth-targeted promotions such as premiums, coupons, sweepstakes, and contests; $2 billion is spent on youth-targeted public relations; and $3 billion is spent on packaging designed for children (McNeal, 1999).

Similarly, young people are major consumers of the products and services of the entertainment, leisure, and recreation industries. An accurate figure for children's and adolescents' comprehensive media and entertainment use is not readily available, though market research suggests there is great potential for the growth of this market; children are being raised in a technology-oriented culture that exposes them to modern media conveniences as noted above (Rideout et al., 2003; U.S. Kids Lifestyles Market Research, 2003). For example, it was projected that $4.2 billion would be spent on children's videos in 2001 (Children's Video Market, 1997) and on a typical day, children aged 4 to 6 years used computers (27 percent) and video games (16 percent) (Rideout et al., 2003).

The quantity and nature of advertisements to which children are exposed to daily, reinforced through multiple media channels, appear to contribute to food, beverage, and sedentary-pursuit choices that can adversely affect energy balance. It is estimated that the average child currently views more than 40,000 commercials on television each year, a sharp increase from 20,000 commercials in the 1970s (Kunkel, 2001). Studies of children's advertising content during that roughly 20-year period found that more than 80 percent of all advertising to children fell into four product categories: toys, cereal, candy, and fast food restaurants (Kunkel, 2001). Moreover, an accumulated body of research reveals that more than 50 percent of television advertisements directed at children promote foods and beverages such as candy, fast food, snack foods, soft drinks, and sweetened breakfast cereals that are high in calories and fat, low in fiber, and low in nutrient density (Kotz and Story, 1994; Gamble and Cotunga, 1999; Horgen et al., 2001; Hastings et al., 2003).

Dietary and other choices influenced by exposure to these advertisements may likely contribute to energy imbalance and weight gain, resulting in obesity (Kaiser Family Foundation, 2004). Based on children's commercial recall and product preferences, it is evident that advertising achieves its intended effects (Kunkel, 2001; CSPI, 2003; Hastings et al., 2003; Wilcox et al., 2004), and an extensive systematic literature review concludes that food advertisements promote food purchase requests by children to parents, have an impact on children's product and brand preferences, and affect consumption behavior (Hastings et al., 2003). Indeed, the 2003 Roper Youth Report10 suggests that an increased number of children aged 8 to 17 years are playing central roles in household purchasing decisions related to food, media, and entertainment (Roper ASW, 2003).

Industry has come to view children and adolescents as an important market force, given their spending power, purchase influence, and potential as future adult consumers (McNeal, 1998). Market research from the early 1990s suggests that children's purchase influence rises with age from $15 billion per year for 3- to 5-year-olds to $90 billion per year for 15- to 17-year-olds (Stipp, 1993). Marketers use a variety of techniques, styles, and channels to reach children and youth, including sales promotions, celebrity or cartoon-character endorsements, product placements, and the co-marketing of brands (Horgen et al., 2001; CSPI, 2003; Hastings et al., 2003; Wilcox et al., 2004).

Research suggests that long-term exposure to such advertisements may have adverse impacts due to a cumulative effect on children's eating and exercise habits (Horgen et al., 2001; CSPI, 2003; Hastings et al., 2003; Wilcox et al., 2004). Children learn behaviors and have their value systems shaped by the media (Villani, 2001). Just as portrayals in television and film shape viewers' perceptions of certain health-related behaviors, such as smoking cigarettes or drinking alcohol, the messages about consuming certain foods and beverages and engaging in sedentary activities may affect them as well (Hastings et al., 2003; Kaiser Family Foundation, 2004).

A recent report issued by the American Psychological Association (APA) Task Force on Advertising and Children concluded that young children (under the age of 8) are uniquely vulnerable to commercial promotion because they lack the cognitive skills to comprehend its persuasive intent; that is, they do not understand the difference between information and advertising (Wilcox et al., 2004). This finding is consistent with the policy statement of the American Academy of Pediatrics that “advertising directed toward children is inherently deceptive and exploits children under eight years of age” (AAP, 1995). A child is unable to critically evaluate these messages' content, intention, and credibility in order to assess their truthfulness, accuracy, and potential bias (Wilcox et al., 2004).

In general, children are exposed to up to one hour of advertising for every five hours of television watched (Horgen et al., 2001). This proportion complies with the Federal Communication Commission's enforcement of the Children's Television Act of 1990, which limits advertising to no more than 12 minutes per hour during the week, and fewer than 10.5 minutes per hour on the weekend, for television programs reaching children under 12 years old (FCC, 2002). However, this exposure to advertising may represent a conservative estimate given the growth in unregulated advertising reaching children through cable television and the Internet (Dale Kunkel, University of Arizona, personal communication, August 17, 2004).

After reviewing the evidence, the committee has concluded that the effects of advertising aimed at children are unlikely to be limited to brand choice. Wider impacts include the increased consumption of energy-dense foods and beverages and greater engagement in sedentary behaviors, both of which contribute to energy imbalance and obesity. The committee concurs with the APA Task Force's finding (Wilcox et al., 2004) that advertising targeted to children under the age of 8 is inherently unfair because it takes advantage of younger children's inability to attribute persuasive intent to advertising. There is presently insufficient causal evidence that links advertising directly with childhood obesity and that would support a ban on all food advertising directed to children. Additional research and public dialogue are needed regarding the potential benefits and consequences of instituting a food advertising ban for children. Recommending a ban may not be feasible due to concerns about infringement of First Amendment rights and the practicality of implementing such a ban (Engle, 2003).

There are historical insights that can be gained from the prior federal government efforts related to advertising food products to children. In 1978, the FTC proposed a rule that would ban or significantly restrict advertising to children, based on a long-standing and widespread concern about the possible adverse health effects from television advertising of food and beverage products to children. The FTC staff sought comment on the issues, including three proposed alternative actions (Engle, 2003).

During this process, the FTC presented a review of the scientific evidence with the conclusion that television advertising directed at young children is unfair and deceptive. The government rulemaking process found that the evidence of adverse effects of advertising on children was inconclusive, despite acknowledging some cause for concern; furthermore, it was found that it would be difficult to develop a workable rule that would address the concerns without infringing on First Amendment rights (Engle, 2003). Congress barred any rule based on unfairness, and the FTC terminated the rulemaking in 1981 (Engle, 2003; Story and French, 2004).

Protecting parents from children's requests for advertised products was not considered a sufficient basis for FTC action at that time. Furthermore, the process identified the complexities of designing implementable rules that restrict advertising directed at children (e.g., how to effectively place limits on the time of day when advertisements could appear and how to define the scope of advertisements directed at young children only) (Engle, 2003). Thus the committee feels that the immediate step is to strengthen industry self-regulation and corporate responsibility. Government agencies should also be empowered to be engaged with industry in these discussions and to monitor compliance.

The committee favors an approach to address advertising and marketing directed especially at young children under 8 years of age, but also for older children and youth, that would first charge industry with voluntary implementation of guidelines developed through diverse stakeholder input, followed by more stringent regulation if industry is unable to mount an effective self-regulating strategy. This approach is similar to that recommended for control of advertising of alcoholic beverages to youth (NRC and IOM, 2003).

It is not possible to determine whether industry self-regulation will lead to a favorable change in marketing and advertising of food and sedentary entertainment11 products to children sooner than governmen- imposed regulation. However, it is desirable that industry is provided with an opportunity to implement voluntary changes to move toward marketing and advertising practices that do not increase the risk of obesity among children and youth, followed by government regulation if voluntary actions are determined to be unsuccessful.

DHHS should convene a national conference and invite the participation of a diverse group of stakeholders to develop standards for marketing of foods and beverages (e.g., portion sizes, calories, fat, sugar, and sodium) and sedentary entertainment (movies, videos and DVDs, and other electronic games). The group should include the food, beverage, and restaurant industries; the Children's Advertising Review Unit (CARU) of the Better Business Bureaus; media and entertainment industries; leisure and recreation industries; public health organizations; and consumer advocacy groups. This national conference should also establish appropriate objectives and methods for evaluating the ongoing effectiveness of the new guidelines.

In addition, further information should be collected about the impact of advertising on children's eating and physical activity behaviors and about how media literacy training may help children and parents make more informed choices.

Implementation of the guidelines will be the responsibility of the food and beverage industry and sedentary entertainment industry trade organizations, individual companies, advertising agencies, and the entertainment industry, with oversight from federal agencies. Appropriate advertising codes and monitoring mechanisms, including industry-sponsored and external review boards (e.g., CARU, National Advertising Review Board), should be implemented to enforce the guidelines. Moreover, industry should take actions to strengthen CARU guidelines and oversight in order to ensure compliance. Through these actions, it is expected that reasonable precautions will be put in place regarding the time, place, and manner of product placement and promotion (i.e., children's morning, afternoon, and weekend television programming and in-school educational programming) to limit children's exposure to products that are not consistent with the principle of energy balance and that do not promote healthful diets and regular physical activity.

Further, Congress should empower the FTC with the authority and resources to monitor compliance with the guidelines, scrutinize marketing practices of the relevant industries (including product promotion, placement, and content), and establish independent external review boards to investigate complaints and prohibit food and beverage and sedentary entertainment product advertisements that may be deceptive or have “particular appeal” to children that conflict with principles of healthful eating and physical activity. Potential guideline elements to consider might be:

  • Restrict or otherwise constrain the content of food and beverage and sedentary entertainment advertising on programs with a substantial children's audience (i.e., children's morning, afternoon, and weekend television programming and in-school educational programming such as Channel One).
  • Avoid implicit or explicit claims that high-energy-density and low-nutrient-density foods have nutritional value.
  • Avoid linking such products to admired celebrities or sports figures, or to cartoon characters. This would include cross-promotion of food and sedentary entertainment products with branded children's programming or networks.
  • Require inclusion of a disclaimer pointing to the need to limit consumption of food or participation in sedentary entertainment.
  • Require a message recommending complementary consumption of healthier food or participation in more physically active entertainment.

Congress should also authorize and appropriate sufficient funding to support a study of the cumulative direct and indirect effects of advertising and marketing on the food and beverage and sedentary entertainment purchasing and health behaviors of children, adolescents, and parents; and investigate how approaches such as media literacy can provide children with the desirable skills to respond to marketing messages.

Recommendation 4: Advertising and Marketing

Industry should develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and youth.

To implement this recommendation:

  • The Secretary of DHHS should convene a national conference to develop guidelines for the advertising and marketing of foods, beverages, and sedentary entertainment directed at children and youth with attention to product placement, promotion, and content.
  • Industry should implement the advertising and marketing guidelines.
  • The FTC should have the authority and resources to monitor compliance with the food and beverage and sedentary entertainment advertising practices.

MEDIA AND PUBLIC EDUCATION

Throughout this report there is discussion of the influence of media on childhood obesity. This section discusses use of the media as a positive strategy for addressing childhood obesity. The fundamental perspective of this report is that childhood obesity reflects numerous influences, and consequently that addressing the epidemic will require changes in the many ways in which American society interacts with its children. Deploying the media should be seen as part of a broader effort to change social norms—for youth about their own behavior, for parents about their actions on behalf of their children, and for society at large about the need to support policies that protect its most vulnerable members.

There is perhaps some irony in using the mass media to address the childhood obesity epidemic when the sedentary lifestyles associated with viewing television are noted to be contributing causes of that epidemic (see Chapter 8). Nonetheless, the committee recognizes that the behaviors associated with the obesity epidemic are widespread, and few other mechanisms are available for stimulating the required changes. Use of the mass media is the best way to reach large segments of the population. At the same time, the committee recognizes that there have been very few efforts to address the problem of childhood and youth obesity through the mass media, thus actions in this domain should be accompanied by careful and continuous monitoring and evaluation to ensure that they are doing what they were meant to do.

Finally, the committee recognizes that if a campaign is not designed with sensitivity, there may be an unintentional consequence that could increase stigmatization of obese children. Stigmatization of smokers was thought to be an effective tool for the tobacco control campaigns; however, obesity may be different. Therefore, the possibility that a campaign could increase negative attitudes and behaviors directed at obese children and youth, such as teasing and discrimination, needs to be explicitly considered in the design and development of the campaign. This should include adequate formative evaluation during development as well as surveillance, concurrent with and following campaign implementation, to detect and minimize any potential adverse effects.

Media-centered efforts must be closely linked with complementary efforts elsewhere in pursuit of the same objectives. For example, a media campaign to recommend that children walk to school might need to be complemented by a public-relations campaign to ensure that there are safe routes for walking, a campaign for reaching parents with a message that they should encourage their children to walk, and a campaign for motivating children to be excited about and interested in walking to school. Thus, media-centered efforts include not only those directed at children and youth themselves, and those directed at parents, but also those directed at policy makers. Throughout this report the committee has emphasized the central role of policy change in obesity prevention, and media-based efforts can have an important role in achieving these changes.

Policy changes occur more quickly if there is a strong social consensus behind them (Economos et al., 2001; Kersh and Morone, 2002). For example, it is worth considering the policy changes that have been important in the success of the anti-tobacco movement (Kersh and Morone, 2002; Daynard, 2003; Yach et al., 2003; see Appendix D). Restrictions on advertising, increases in taxation, and controls over smoking-permissible locations were important components of the tobacco-use decline (Hopkins et al., 2001), but these changes could be readily implemented only because a new public-opinion climate around tobacco supported them and permitted legislators and regulators to act (Kersh and Morone, 2002; Yach et al., 2003). This public opinion transformation likely resulted both from the natural diffusion of information about the health consequences of tobacco use and the deliberate efforts by advocacy agencies to affect public opinion (Warner and Martin, 2003). Similarly, it will likely be easier to implement policies to prevent childhood obesity if the general public is informed about the issues and strongly supportive of the need to address them.

Lessons Learned from Other Media Campaigns on Public Health Issues

A number of media campaigns covering a range of public health issues have been targeted to adults or the general public. For example, media efforts were successfully used to encourage parents to put their infants to sleep on their backs to avoid Sudden Infant Death Syndrome (Moon et al., 2004) and to discourage the use of aspirin for children's fevers to avoid Reye's syndrome (Soumerai et al., 1992). The outcomes of the “Back to Sleep” and the Reye's syndrome campaigns were encouraging, but their objective may be simpler than the sorts of actions recommended for energy-balance campaigns. A major national effort to encourage parents to monitor their children so as to reduce their risk of drug use has not yet shown evidence of behavior change, although it is still ongoing (Hornik et al., 2003).

A broader range of campaigns addressing parents' own behaviors related to energy balance has shown mixed results. Evaluations of a series of mass-media-based interventions undertaken in the 1990s to promote adult physical activity provide a mixed picture of success, with most reporting fairly good levels of recall of messages and changes in knowledge about the benefits of exercise. Only sometimes, however, did results show evidence of actual increases in self-reported physical activity, even over the short term (Owen et al., 1995; Vuori et al., 1998; Wimbush et al., 1998; Bauman et al., 2001, 2003; Hillsdon et al., 2001; Miles et al., 2001; Reger et al., 2002; Renger et al., 2002).

In addition to these predominantly mass-media-focused efforts, there were other multicomponent campaigns for which mass media was but one (albeit important) channel that addressed not only physical activity but other outcomes as well (see Chapter 6). Initial success from the Stanford Three Community Study and the North Karelia Project demonstrated the promise of this approach, and were followed by three large National Heart, Lung, and Blood Institute-funded community trials in the 1980s—the Stanford Five-City Project, the Minnesota Heart Health Program, and the Pawtucket Heart Health Program (Farquhar et al., 1990; Luepker et al., 1994; Carleton et al., 1995). The multiyear Minnesota Heart Health Program reported greater adult physical activity in its experimental communities than in its control communities (Luepker et al., 1994); and the Stanford Five-City Project reported similar patterns (Young et al., 1996), as well as lower resting heart rate (a measure of cardiorespiratory fitness), lower blood pressure, and lower body mass index levels (Taylor et al., 1991; Farquhar et al., 1990) in the intervention communities. The Stanford and Minnesota projects included change in diet among their objectives, but these studies did not report notable successes in affecting dietary fat or dietary cholesterol, although an effect on plasma cholesterol was reported in the Stanford Five-City Project (Farquhar et al., 1990).

There were also a small number of evaluated mass-media interventions focused on diet. These included the “1% or Less” campaign in Wheeling, West Virginia, which showed that more adults in the state switched to low-fat milk than in a control community after a campaign in 1996 (Reger et al., 1999); and the Victoria, Australia's “2 Fruit ‘n’ 5 Veg Every Day” campaign that ran from 1992 to 1995, which showed some increase in reported consumption of these targeted foods (Dixon et al., 1998).

The National Cancer Institute-sponsored “5 A Day for Better Health” program, for which mass-media promotion of fruit and vegetable consumption was a component, showed varying degrees of success. California data for the initial “5 A Day for Better Health” program from 1989 to 1991, as well as the subsequent national program, revealed small increases in consumption of daily servings of fruit and vegetables, though evaluators suggested that these may well have reflected ongoing secular trends (Foerster et al., 1995) or demographic shifts (Stables et al., 2002).

The findings on diet interventions, like those regarding physical activity, clearly were mixed. The 5-A-Day evaluations represented efforts of a different magnitude than any of the described physical activity interventions, yet there were no clear associations between those efforts and dietary changes. These results are of concern when considering large-scale dietary interventions. At the same time, it is evident that substantial changes in the U.S. adult diet have occurred during the last few decades, most strikingly in the reduction of dietary cholesterol and resulting levels of plasma cholesterol (Frank et al., 1993). Although evaluations of deliberate campaigns may not show consistent evidence of influence on dietary intake and outcomes, there are some influences producing large shifts in dietary knowledge and behavior. The idea that such shifts reflect general media coverage of dietary issues, creating in turn a substantial demand for low-cholesterol, low-fat products, and more recently, low-carbohydrate products, is worth serious consideration.

Approaches that seek to affect the shape of media coverage of diet and/or physical activity might merit high priority. One of the most difficult barriers to successful public education programs is achieving high rates of exposure to persuasive messages. Even if a carefully mounted intensive education effort was effective for the audience it could reach, it may not be feasible to reach large audiences with those messages. Resources may not be available to pay for the outreach channels and prime time exposure for target groups needed on a continuing basis. In contrast, ordinary mass-media programs and news do reach large audiences with their messages. They can achieve high and continuing exposure to healthy messages.

Such heavy exposure may be effective for a variety of reasons: sheer repetition so that messages (1) may be more likely to be heard and paid attention to, particularly if the repetition occurs across a variety of channels; (2) may communicate social expectations for behavior, and (3) may produce a greater likelihood of community discussion of the message possibly producing personal reinforcement for behavior change.

Thus if the media cover an issue extensively, it may be possible to achieve changes in behavior not practicable with controlled educational interventions. However the problem for programs that take this route is the difficulty of convincing media to cover an issue in a way consistent with sponsors' goals. The solutions that people have used include buying or obtaining donated advertising time; engaging in media advocacy—a deliberate attempt to create controversy or to leverage a news event to stimulate media coverage of an issue (Wallack and Dorfman, 1996); undertaking public relations efforts to encourage media coverage; and working with producers and writers of entertainment programs or talk shows to encourage incorporation of messages in those programs. Different programs have used each of these strategies, with varying success (Wallack and Dorfman, 1996; Hornik et al., 2003; Wray et al., 2004).

In March 2004, DHHS announced an obesity-focused campaign called “Small Steps” that is comprised of a series of public service announcements recommending that Americans take small and achievable steps toward increasing physical activity and reducing calorie consumption to improve their health and reverse the obesity epidemic (DHHS, 2004). The initiative and advertisements provide suggestions such as choosing fruit for dessert and doing sit-ups in front of the television—easily accomplished actions that DHHS anticipates will appeal to Americans searching for achievable weight-management goals. The campaign, which is part of a larger DHHS effort, the Steps to a Healthier U.S. Initiative, is addressed both to adults and children and is implemented through awards to large urban communities, rural communities, and tribal consortiums. Because this program was launched as this report was being written, results on effectiveness are not yet available.

Over the past 10 years, government and private groups have undertaken major media campaign efforts to influence a variety of other youth behaviors, including tobacco use and drug use. Current evidence suggests that the anti-tobacco campaigns have been successful, while the anti-drug campaigns have had less success. Tobacco use among youth has been declining since 1997, and there is evidence linking some of that decline to state-level media campaigns (Siegel, 2002). In contrast, the National Youth Anti-Drug Media Campaign, sponsored by the White House Office of National Drug Control Policy, has not shown success thus far in influencing youth marijuana consumption, despite having spent more than $1 billion in advertising and other efforts (Hornik et al., 2003). The inconsistent results from these two areas do not lead to easy conclusions about whether media campaigns are promising for obesity-related behaviors. They do suggest that the success of such campaigns will depend on the outcome sought and the ways in which the campaigns are mounted and maintained.

Industry-sponsored efforts to encourage increased levels of physical activity are currently under way (Nike, 2004), though the committee does not have any information about their possible influence of these efforts on youth behavior. The advantage of such industry-sponsored programs is that they do not require explicit public investment; however, reasonably enough, they will reflect their sponsors' interests, which may not always coincide with the agendas of those primarily concerned with youth obesity. In circumstances where they might play a useful complementary role in a national effort, industry-sponsored efforts should certainly be encouraged. However, national authorities must understand that such campaigns are likely to be only one part of a broad effort, and should not be seen as an alternative to mounting an urgent public-sector campaign focused on behavioral objectives.

Within the past two years, the Centers for Disease Control and Prevention (CDC) has launched the VERB campaign, a multi-ethnic media campaign based on social marketing principles and behavioral change models (Huhman, et al., 2004) with the goal of increasing and maintaining physical activity in tweens—youth aged 9 to 13 years. Parents and other influential sources on tweens (e.g., teachers and youth program leaders) are the secondary audiences of the VERB campaign. The CDC has conducted extensive formative research to design this social marketing campaign (Wong et al., 2004), which currently involves multiple media venues that include television, radio spots, print advertising, posters, the Internet, and out-of-home outlets such as movie theaters, billboards, and city buses (Wong et al., 2004).

A recently released summary of the VERB campaign's first-year results of a prospective study suggests a high recall of messages and some evidence that youth who had better campaign recall engaged in more physical activity than those who did not (Potter et al., 2004). It should be noted, however, that the extent to which the association between campaign recall and greater physical activity can be attributed to the campaign's influence cannot be determined from these results. One cannot rule out the alternative explanation that youth who are more naturally oriented toward being more physically active are also more likely to recall the campaign messages. Given these preliminary, albeit positive results, and no other available evaluations of media campaigns, it is not possible at present to state that media campaigns can effectively increase physical activity in children aged 9 to 13 years.

Next Steps

The committee recognizes that there is limited evaluated experience in mass-media-centered interventions that address obesity prevention. Nonetheless, there is substantial experience in other related areas, along with the initial findings of positive evidence from some very recent obesity-focused efforts. In addition, the committee recognizes that most of its recommendations throughout the report require reaching the population at large, on a continuing basis, to generate popular support for policy changes and provide needed information to parents and youth about behaviors likely to reduce the risks of obesity. Only the mass media offer the possibility of reaching that sizeable and wide-ranging audience.

Thus the committee recommends that DHHS, in coordination with other federal departments and agencies and with input from independent experts, develop, implement, and rigorously evaluate a broad-based, long-term, national multimedia and public relations campaign focused on obesity prevention in children and youth. This campaign would vary in its focus as the nature of the problem changes, including components focused on changing eating and physical activity behaviors among children, youth, and their parents as well as on raising support among the general public for policy actions. The outcome of this effort should be greater awareness of childhood obesity, increased public support for policy actions, and behavior change among parents and youth.

The three areas of focus for the recommended media campaign would involve:

  • A continuing public relations or media advocacy effort designed to build a political constituency for addressing youth obesity, and for supporting specific policy changes on national, state, or local levels. This will include print and broadcast media press briefings and outreach, media support for other organizations focused on obesity issues, and efforts to encourage commercial media to incorporate obesity issues and positive role modeling in their programming.
  • A systematic and continuing campaign to provide parents with the types of information described in Chapter 8, including the importance of serving as role models and of establishing household policies and priorities regarding healthful eating and physical activity.
  • A systematic and continuing campaign to reach youth who are themselves making energy balance decisions that affect their risk of obesity.

The federal government's recently launched VERB campaign is one example of a youth-focused campaign and presents an opportunity to examine the long-term impact of a multimedia campaign focused on promoting physical activity in youth, one component of preventing obesity. As noted above, preliminary results are positive for an early phase of the campaign. CDC has made substantial investment in this program and, given the positive first results, further investments should follow over a longer term.

Regarding the systematic campaign to reach youth, the committee specifically endorses the continuation of VERB funding to ensure the possibility of fully realizing the social marketing campaign's potential and to evaluate its long-term impact. This proposal is costly. Thus, based on a rigorous evaluation over the long term, resources should be redirected if results are not promising in meeting the three components of the campaign. In addition, the committee notes that physical activity is but one side of the energy equation. Additional resources should be provided for a complementary campaign focusing on energy-intake behaviors.

Funding for the national multimedia and public relations campaign should include sufficient budgets to purchase media time for the campaign's advertising, rather than relying on donated time, as well as to support the professional implementation and careful evaluation of the campaign's effects. While DHHS's Small Steps program intends to depend on contributed airtime under the auspices of the Advertising Council (DHHS, 2004), the committee suggests that it is not a promising route for frequently reaching the public. A recent Kaiser Family Foundation study showed that the average television station rarely plays such public service announcements during periods when most adults are in the viewing audience (Kaiser Family Foundation, 2002). Some campaigns have had success in obtaining donated time on stations where they had also purchased time (Randolph and Viswanath, 2004), but that is merely a strategy for stretching resources more effectively. In general, a campaign that depends on contributed time is quite unlikely to satisfy its objectives.

Input should be sought from independent experts and representatives of other federal, state, and local agencies, nonprofit organizations, and, where appropriate, industry representatives to construct a broad and evolving strategy that includes all three of the areas of focus described above. These efforts, which need a long-term mandate from Congress, should be aimed at the general population and specific high-risk subgroups, and their staffs should be able to carefully assess targets of opportunity and rebalance their strategies as circumstances change.

The committee realizes that many nonprofit organizations and other nongovernmental groups are involved in obesity prevention efforts. It encourages these organizations to undertake their own extensive media campaigns (print, electronic, Web-based, and other media) for addressing the obesity problem.

Recommendation 5: Multimedia and Public Relations Campaign

DHHS should develop and evaluate a long-term national multimedia and public relations campaign focused on obesity prevention in children and youth.

To implement this recommendation:

  • The campaign should be developed in coordination with other federal departments and agencies and with input from independent experts to focus on building support for policy changes, providing information to parents, and providing information to children and youth. Rigorous evaluation should be a critical component.
  • Reinforcing messages should be provided in diverse media and effectively coordinated with other events and dissemination activities.
  • The media should incorporate obesity issues into its content, including the promotion of positive role models.

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Footnotes

1

Active living is a way of life that integrates two types of physical activity—recreational or leisure activity (e.g., jogging, skateboarding, or playing basketball), and utilitarian or occupational activity (e.g., walking or bicycling to school or running errands)—into one's daily routine.

2

In this report the term “kilocalories” is used synonymously with “calories.”

3

A serving size is a standardized unit of measure used to describe the total amount of foods recommended daily from each of the food groups from the Food Guide Pyramid (FGP) or a specific amount of food that contains the quantity of nutrients listed on the Nutrition Facts panel. A portion size is the amount of food an individual is served at home or away from home and chooses to consume for a meal or snack. Portions can be larger or smaller than serving sizes listed on the food label or the FGP (USDA, 1999).

4

Under the Nutrition Labeling and Education Act of 1990, food products exempted from calorie and nutrient labeling include foods served for immediate consumption, ready-to-eat food not for immediate consumption (i.e., take-out foods), and foods produced by small businesses with annual sales below $500,000 (IOM, 2004).

5

An example of an adapted FGP is the Radiant Pyramid, a daily food guide based on the concept of nutrient density. The most nutrient-dense food choices, at the bottom of the pyramid, should be consumed in appropriate serving sizes frequently, whereas the most energy-dense food choices at the (much smaller) top of the pyramid should be consumed only occasionally (Porter Novelli, 2003).

6

A “qualified” health claim uses appropriate qualifying language to describe the level of scientific evidence that the claim is truthful. The FDA offers guidance, including a method for systematically evaluating the evidence, on the review process for developing qualified health claims (IOM, 2004).

7

As discussed in Chapter 3 and Appendix B, beverages (such as soft drinks and fruit drinks), due to their high water content, are generally not energy dense. However, the energy density of soft drinks is disproportionately high for its nutrient content when compared to other nutrient-dense beverages such as low-fat milk. Therefore, comparisons of beverages should involve considerations of nutrient density.

8

A nutrient content claim is an FDA-regulated statement on food packages that characterizes the level of a nutrient in a food such as “free,” “high,” “low,” “more,” and “reduced”. The NLEA (1990) allows the use of nutrient-content claims that describe the amount of a nutrient according to the FDA's authorizing regulations (IOM, 2004).

9

Comparative claims are a subset of nutrient content claims. Under NLEA rules, comparative claims are required to meet a number of specific restrictions and disclose the comparison product, the percentage that a nutrient is reduced, and the actual amount of the nutrient for both the product and the comparison food (Ippolito and Pappalardo, 2002).

10

The 2003 Roper Youth Report, based on a nationwide cross-sectional cohort of 544 children aged 8 to 17 years, was conducted by Roper ASW, a market-research firm. Face-to-face interviews were conducted in children's homes in 2003 (Roper ASW, 2003).

11

Sedentary entertainment refers to activities and products that require minimal physical activity and encourage physical inactivity such as watching television, video rentals, and spectator sports.

Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK83815

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